Home Administrative Billing & Reimbursement Health and Wellness Medical PEAR portal Pharmacy Products Quality Management

Upcoming changes to claims reporting requirements for home infusion providers

January 29, 2016

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Effective March 1, 2016, AmeriHealth will adopt new claims reporting requirements for drugs obtained from in-network home infusion providers. The following information will be required when submitting drug claims for home infusion vendors that are not owned by a hospital or health system in the AmeriHealth provider network:

  • NDC. The specific National Drug Code (NDC) that corresponds to the drug formulation administered to the member must be reported.
  • HCPCS or CPT® codes. The specific Healthcare Common Procedure Coding System (HCPCS) or Current Procedural Terminology (CPT) code for the drug must be reported. Exception: For drugs without a specific HCPCS or CPT code, report the J3490 or J3590 not otherwise classified (NOC) code, as appropriate.
  • Units of drug administered. Drug units must be reported in multiples of the dosage unit specified in the HCPCS/CPT code narrative. Exception: For drugs without a specific HCPCS or CPT code, report the units in multiples of the drug units specified in the NDC.
Failure to include these components in a claim may result in delayed processing and reimbursement.

Note: Precertification requests submitted through the NaviNet® web portal will continue to follow the same submission process that is in effect today.

For more information

The following claim payment policies are being updated to address these new billing requirements and provide specific claims examples:

  • Commercial: #00.01.49b: Reporting Requirements for Drugs and Biologics
  • Medicare Advantage: #MA00.024a: Reporting Requirements for Drugs and Biologics
View the Notifications for these policies by visiting our Medical Policy Portal. Select Accept and Go to Medical Policy Online, and then select Commercial or Medicare Advantage under Active Notifications.

We ask that you review these policies in their entirety and share them with your staff so they can become familiar with the new requirements prior to March 1, 2016.

Please note that this change only applies to home infusion vendors that are not owned by hospitals or health systems in the AmeriHealth provider network. Home infusion vendors owned by hospitals or health systems in the AmeriHealth provider network should continue to bill according to the terms of their contract.

NaviNet is a registered trademark of NaviNet, Inc.

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